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The Written Medical Record

The Written Medical Record

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The Written Medical Record

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  1. The Written Medical Record Communication Skills II

  2. Purpose • Memory Aid • Communication • Quality Assessment • Research • Legal Matters • Insurance Matters

  3. Your Audience • You • Other Health Care Providers • Lawyers • Quality Assurance • Utilization Review Committees • Administrators • Insurance Companies • Researchers

  4. Types of Notes • Complete History and Physical (H&P) • Problem Focused Note • Interim Note • Surgery/procedures • Hospitalization • Admission Note • Progress Note • Discharge Summary

  5. Organization of Notes • SOAP format • Subjective • Objective • Assessment • Plan

  6. Subjective Identifying Data Source/Reliability Chief Complaint History of Present Illness Past Medical History Family History Patient Profile/Social History Review of Systems Objective Physical Exam Laboratory Data Assessment Problem List Impression/Diagnosis Plan Treatment Disposition Organization of Notes

  7. Identifying Data Name age gender occupation marital status Source/Reliability historian’s identity reliability judgement Chief Complaint verbatim QUOTES Subjective

  8. Subjective • History of Present Illness • Selection and interpretation` • Detailed chronological description • Date symptoms and events • Absence of key symptoms • Relevant facts from PMH, FH, SH, ROS • Positive data before negative data • Symptom vs sign

  9. Subjective • Past Medical History- • list, dates, other relevant information • illnesses, hospitalizations and surgeries • accidents and injuries • pregnancies, deliveries, complications • allergies and reactions • medications including OTCs • immunizations and health maintenance

  10. Subjective • Family History • history of family illnesses • major • genetic/hereditary/familial • cause of death • tabular or genographic • three generations

  11. Subjective • Patient Profile and Social History • Brief biographical narrative • birth, education, military • living situation • occupational history • life style - personal interests, travel • typical day • relevant feelings and beliefs • List • health habits - EtOH, tobacco, drugs • diet, exercise

  12. Subjective • Review of Systems • List all positive and negative findings in complete sentences • See pages 26 and 869

  13. Subjective • Identifying Data: • Mrs. Reynolds is a 58-year-old bank executive who lives with her husband and mother-in-law. • Source: • Mrs. Reynolds provides her own history and is reliable and accurate. • Chief Complaint: • "I can't eat" for the past 3 or 4 months.

  14. Subjective • History of Present Illness • The patient, who has a 10 year history of diabetes and hypertension, complains of anorexia for the past a 3 to 4 months and a 19 lb weight loss. She tires easily and has been obliged to stop volunteer hospital work and take a nap each afternoon. She thinks this may well be related to her nerves since she has been depressed about her divorced daughter.She denies nausea, vomiting, diarrhea, excess thirst, polyuria, headache, dizziness, visual disturbance, dyspnea on exertion, swollen legs, and palpitations

  15. Subjective • Past Medical History • Allergies - sulfa (rash/hives) • Childhood illnesses - chicken pox, scarlet fever • Adult illnesses - • diabetes mellitus, type II, X 10 years • hypertension diagnosed 1991 • Hospitalization/Surgery • Cholecystectomy 1981

  16. Subjective • Past Medical History (con’t) • Obstetrical History - G3P3003 • Medications • Glucophage 1000 mg BID • Avandia 4 mg qd • Prinivil 20 mg qd • Immunizations/Health Maintenance • Hepatitis B series - 2000 • Tetanus 1999 • Last pap - 9/2000; mammogram - 9/2000

  17. Subjective • Family History • Father - 32 years old; accidental death; diabetes • Mother - 80 years old; deceased - stomach cancer • Sister - 56 years old; alive and well • Sister - 55 years old; hypertentsion • Brother - 60 years old; diabetes • 2 sons (20 and 22 years old) - alive and well • Daughter 26 years old - alive and well

  18. Subjective • Patient Profile • Mrs. Smith is an intelligent, somewhat anxious woman who shows normal concern for her symptoms and possible illnesses. She thinks her troubles are due to nerves but isn't sure. She is a sturdy, considerate, kind woman who cares for her husband and seems well adjusted. She has lived in Pennsylvania all her life until 7 years ago when she moved to Virginia due to her husband's work. He is a construction foreman and has always provided well.

  19. Subjective • Patient Profile (con’t) • Mrs. Smith dropped out of college to get married and although her formal education stopped she has kept busy reading, doing charity work, and watching TV. She knits, likes to dance, although she fatigues too much for that now, attends church regularly, and seems to have good psychosocial and sexual relationships with her husband. She gets to bed by 11, is up at 7, makes breakfast and lunch for her husband, naps in the afternoon, makes dinner, and she and her husband clean up together.

  20. Subjective • Social History • Smoking - none • Alcohol - one or two cocktails on weekends. • Recreational drugs - denies • Caffeine - two to three cups of coffee or tea daily • Diet - Cereal and fruit for breakfast; sandwich or salad for lunch; rice, vegetable and meat or fish for dinner. Does not snack. • Exercise - none

  21. Subjective • Review of Systems • General: There have been no chills or fever and she considers herself in good health until recently. • Head: She has no headaches or dizziness. • Skin, Hair, Nail: She has had thinning of the hair for 10 years. Here are no unusual nails or skin changes . • Eyes, Ears, Nose, Throat: She wears glasses and has no spots before the eyes, visual difficulty, inflammation or eye pain, double vision, or tearing. She has good hearing and no tinnitus or aural discharge. She has no teeth and wears dentures. She gets a little hoarse sometimes but attributes this to her husband's deafness.

  22. Subjective • You will not record ALL of the data • Pertinent negatives • No assessment, diagnoses or impressions • Pain scale, activity • Symptom vs sign

  23. Objective • Physical exam findings • general statement and vital signs • fully describe: • skin, HEENT, neck, lymph, breasts, lungs, heart, abdomen, rectum, GU, (extremities), musculoskeletal, neurological, mental status. • Known laboratory/procedure results

  24. Location - landmarks, clock Incremental grading - murmur, strength Discharge Illustrations Organs, masses, lesions texture/consistence size shape and configuration mobility inflammation color location other Objective

  25. Assessment • Problem list • known diagnoses • symptom • sign • laboratory abnormality • personal, social, financial, functional difficulty • Diagnoses • diagnosis with rational from database or • prioritized differentials

  26. Plan • Tests to be performed or ordered • Therapeutic treatment/medication • Patient education • Referral • Follow up

  27. Use outline format Use headings Be concise Be accurate Use quotes Write legibly Line out errors Initial & date changes Defer w/ reason Use complete sentences Use present tense Use ink Sign properly Document soon DO

  28. Do NOT • Identify patient • Use abbreviations • Use good, negative, normal, abnormal • Record false data • Obliterate errors or erase • Omit data • Leave blank spaces • Take copious notes/write too soon